=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275699621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA PERSONAL GROWTH CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 W COMMERCIAL BLVD SUITE 305
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-733-3394
-----------------------------------------------------
Fax | 954-733-4483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3511 W COMMERCIAL BLVD SUITE 305
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-733-3394
-----------------------------------------------------
Fax | 954-733-4483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CAREN J GLASSMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-733-3394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 2998
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------